Care plan · Robert L. Hawkins
Active · v3.2 · last updated 5/19 by you · shared with Dr. Reyes, Caliber Pharmacy
Goals
- Prevent psychiatric hospitalization (next 12 mo)Owner: Janelle (CM) · Status: at risk · last admit 11/2024
- PHQ-9 ≤ 9 sustained for 90dOwner: Dr. Reyes · Status: regressing (currently 14)
- Clozapine adherence ≥ 95%Owner: Caliber Pharmacy · Status: at risk (2 gaps in 60d)
- Stable weight (CHF management)Owner: PCP · Status: trending up (+3 lb / 5d)
Active interventions
| Intervention | Cadence | Last | Status |
|---|---|---|---|
| Weekly SMS PHQ-9 | Mon 9a | 5/16 | Active |
| Voice check-in | Biweekly Sat | 5/18 | Active |
| Care manager call | As needed | 5/19 | Active |
| Home scale (CHF) | Daily | today | Active |
| Pharmacy auto-refill | 28d cycle | 5/10 | Review |
| Psychiatry f/u | Monthly | 5/14 | Active |
Crisis protocol
- Daughter (Sarah, HIPAA auth on file) — 919-555-0148
- Dr. Reyes direct line — answered M-F 8a-5p
- Caliber mobile crisis team — dispatched within 60 min
- WakeBrook Crisis Center — preferred (prior positive experience)
Care team
- Janelle Ortiz, LCSWCare manager · primary
- Dr. M. Reyes, MDPsychiatrist · 11 mo
- Dr. D. Mehta, MDPCP
- Caliber PharmacyClozapine specialty pharmacy
- Sarah HawkinsDaughter / caregiver
Caliber recommendation
Given current trajectory, the model suggests adding a 3rd weekly SMS touchpoint and shortening psych f/u from 4w to 2w until PHQ-9 stabilizes.
Social context
- Lives alone, apt complex
- Daughter visits 2x/week
- Reports neighbor disturbance (under investigation)
- Transportation: own car, drives locally only
- SNAP enrolled, food access stable